Addressing muscle performance impairments in cerebral palsy: Implications for upper extremity resistance training

Effects of Therapies Involving Plyometric-Jump Training on Physical Fitness of Youth with Cerebral Palsy: A Systematic Review with Meta-Analysis

The aim of this systematic review was to assess the effects of plyometric-jump training (PJT) on the physical fitness of youth with cerebral palsy (CP) compared with controls (i.e., standard therapy). The PRISMA 2020 guidelines were followed. Eligibility was assessed using the PICOS approach. Literature searches were conducted using the PubMed, Web of Science, and SCOPUS databases. Methodological study quality was assessed using the PEDro scale. Data were meta-analyzed by applying a random-effects model to calculate Hedges' g effect sizes (ES), along with 95% confidence intervals (95% CI). The impact of heterogeneity was assessed (I2 statistic), and the certainty of evidence was determined using the GRADE approach. Eight randomized-controlled studies with low-to-moderate methodological quality were included, involving male (n = 225) and female (n = 138) youth aged 9.5 to 14.6 years. PJT interventions lasted between 8 and 12 weeks with 2-4 weekly sessions. Compared with controls, PJT improved the muscle strength (ES = 0.66 [moderate], 95% CI = 0.36-0.96, p < 0.001, I2 = 5.4%), static (ES = 0.69 [moderate], 95% CI= 0.33-1.04, p < 0.001, I2 = 0.0%) and dynamic balance (ES = 0.85 [moderate], 95% CI = 0.12-1.58, p = 0.023, I2 = 81.6%) of youth with CP. Therefore, PJT improves muscle strength and static and dynamic balance in youth with CP compared with controls. However, more high-quality randomized-controlled trials with larger sample sizes are needed to provide a more definitive recommendation regarding the use and safety of PJT to improve measures of physical fitness.

The effect of proprioceptive neuromuscular facilitation on functional skills, muscle strength, and trunk control in children with cerebral palsy: A randomized controlled trial

BACKGROUND

Proprioceptive neuromuscular facilitation (PNF) is generally used for the lower limbs in children with Cerebral Palsy (CP). This study aimed to determine the effect of PNF and Neurodevelopmental Therapy (NDT) on functional abilities, muscle strength, and trunk control in children with CP.

METHODS

Thirty spastic CP children classified as either level I-II in the Gross Motor Function Classification System (GMFCS) or level I-II in the Manual Ability Classification System (MACS) were included. The PNF (n = 15) and the NDT group (n = 15) had physiotherapy for six weeks. The ABILHAND-Kids scale, the Purdue Pegboard Test (PBPT), the Nine-Hole Peg Test (9-HPT), and the Jebson-Taylor Hand Function Test (JTHFT) were employed. Pinch meters, Jamar handheld dynamometers, and digital muscular strength assessments were used.

RESULTS

The PNF group increased shoulder flexion (p < 0.05), adduction (p < 0.05), elevation (p < 0.05), scapular abduction (p < 0.05), elbow extension (right) (p < 0.05), grip (p < 0.05), and pinch strengths (left p < 0.05, right p < 0.05). The PNF group had significantly lower 9-HPT (p < 0.05), JTHFT (card turning), JTHFT (simulated feeding), JTHFT (lifting light cans), and JTHFT (lifting weight cans) durations (p < 0.05), and significantly higher PBPT (right-left) PBPT (bimanual), PBPT (assembly). (p < 0.05), ABILHAND (p < 0.05), and TCMS total scores (p < 0.001). While JTHFT (simulated feeding-left), JTHFT (stacking checkers-left), JTHFT (lifting light cans-left), and JTHFT (lifting weight cans-right/left) (p < 0.05) durations decreased in the NDT group, PBPT (right) (p < 0.05) had an increase in duration.

CONCLUSION

PNF improves trunk control, upper extremity functional skills, selective proximal muscle strength, and distal upper extremity muscle and grip strength.

Effectiveness of Power Exercises Compared to Traditional Strength Exercises on Motor Skills, Muscle Performance and Functional Muscle Strength of Children with Attention Deficit Hyperactivity Disorder: A Single-Blind Randomized Controlled Trial

The aim of this study was to compare the impact of 8-weeks of power exercises compared to traditional strength exercises on motor abilities, muscle performance, and functional strength in children with ADHD. A total of 34 children with ADHD were randomized into two groups to receive functional power training (n = 17, M age: 121.2 ± 16.6 months) and traditional strength training (n = 17, M age: 116.1 ± 13.4 months). After the 8-week intervention, two-way ANOVA results with 95% confidence intervals showed no differences between the groups in motor skills, muscle power, or functional muscle strength. However, the functional power training group had larger effect sizes and greater increases in total motor composite score (10% vs 7%), body coordination (13.8% vs 4.9%) and bilateral coordination (38.8% vs 27.9%) than the traditional strength training group. The power training group also exhibited catch-up growth with typically developing peers. These findings suggest that power exercises may be more effective than strength exercises for rapid force generation in daily life, particularly for children with ADHD.

The effects of power exercises on body structure and function, activity and participation in children with cerebral palsy: an ICF-based systematic review

PURPOSE

To systematically review the literature for evidence of effectiveness of power exercises on physical, physiological, and functional outcomes in children and adolescents with cerebral palsy (CP).

MATERIALS AND METHODS

Methodological quality and evidence synthesis were assessed with using the Cochrane Risk of Bias (RoB) Tools and Modified Bakker Scale. Using the International Classification of Functioning (ICF), outcome measures for muscle agriculture, gait, balance, motor function, aerobic/anaerobic fitness, daily living, mobility, and school participation were categorised.

RESULTS

The overall RoB of four randomised clinical trials was low, one had some concerns and two were rated as high. Moderate evidence was found that power exercises increased walking speed, activities of daily living, muscle strength, and enhanced gross motor function more than a routine physical therapy program.

CONCLUSIONS

The lack of stronger evidence for power training interventions to improve muscle architecture, muscle function, walking capacity, and mobility in children with CP might be explained by the differences in training protocols and degree to which these meet the physiological definition of power, different methods of measuring power, limited durations of training, and the relative effectiveness of control interventions. Future studies should include a stronger focus on child and family-centred participation goals.Implications For RehabilitationPower training can improve gross motor function, walking speed, muscle strength, and activities of daily living more than routine physical therapy.Results comparing power training versus traditional strength training were less pronounced likely because both are intensive and may have positive effects.More research is needed to investigate effects of power training on participation.

The association between isometric strength and cognitive function in adults with cerebral palsy

Background

The literature supports quantifying the maximum force/tension generated by one's forearm muscles such as the hand grip strength (HGS) to screen for physical and cognitive frailty in older adults. Thus, we postulate that individuals with cerebral palsy (CP), who are at higher risk for premature aging, could benefit from tools that objectively measure muscle strength as a functional biomarker to detect frailty and cognitive decline. This study assesses the clinical relevancy of the former and quantifies isometric muscle strength to determine its association with cognitive function in adults with CP.

Methods

Ambulatory adults with CP were identified from a patient registry and were enrolled into this study. Peak rate of force development (RFD) and maximum voluntary isometric contraction of the quadriceps were measured using a commercial isokinetic machine, while HGS was collected with a clinical dynamometer. Dominant and non-dominant side were identified. Standardized cognitive assessments, including the Wechsler Memory and Adult Intelligence Scales IV, Short Test of Mental Status, and the Patient-Reported Outcomes Measurement Information System (PROMIS®) were used to evaluate cognitive function.

Results

A total of 57 participants (32 females; mean age 24.3 [SD 5.3]; GMFCS levels I-IV) were included in the analysis. Although dominant and non-dominant RFD and HGS measures were associated with cognitive function, non-dominant peak RFD showed the strongest associations with cognitive function.

Conclusion

RFD capacity may reflect age-related neural and physical health and could be a better health indicator than HGS in the CP population.

Combined Effects of Mirror Therapy and Exercises on the Upper Extremities in Children with Unilateral Cerebral Palsy: A Randomized Controlled Trial

Purpose: This study investigated the combined effects of mirror therapy involving power and strength exercises of the upper extremities in children with Unilateral Spastic Cerebral Palsy (USCP).Methods: Thirty children were included in either an experimental group or a control group. All participants were evaluated with the Quality of Upper Extremity Skill Test (QUEST), Canadian Occupational Performance Measure (COPM), and a handheld dynamometer to measure isometric muscle strength.Results: Compared to the control group, greater improvement was found in dissociated movements (p < .001, d = 1.82), grasp (p < .001, d = 1.38), weight bearing (p = .006, d = 0.91), and total scores (p = .001, d = 1.16) of QUEST; performance (p < .001, d = 2.9), satisfaction (p < .001, d = 1.91), and total scores (p < .001, d = 2.87) of COPM; and isometric muscle strength of the biceps brachii (p < .001, d = 1.27) and triceps brachii (p = .002, d = 2.22) of the affected upper limbs in the experimental group.Conclusions: Mirror therapy combined with power and strength exercises is a promising intervention approach to improve activity performance and upper-limb function in children with USCP.

Community-Based Upper Extremity Power Training for Youth with Cerebral Palsy: A Pilot Study

Aim: To examine the effects of an upper-extremity, community-based, and power-training intervention.Methods: Twelve participants with cerebral palsy (CP) [8 males, 4 females; mean age 14 years 6 months (SD 5 years 4 months), range 7-24] were randomly assigned to a rest-training (RT; n = 6) or training-rest (n = 6) group in this randomized, cross-over design. Training took place in participants' home or school, three times per week for 6 weeks. We examined changes in upper extremity average power output (Pavg) in watts (W) and changes in function via the Pediatric Outcomes Data Collection Instrument (PODCI).Results: Each participant completed at least 15 of the 18 total training sessions (91.2% adherence). Pavg increased 92.2% on average among participants (p < .05). There was a significant three-way interaction among treatment, sequence, and period with the data stratified by (Bimanual Fine Motor Function [BFMF]) level on the pain subscale of the PODCI (p = 0.0118). All participants decreased pain after training with the exception of individuals with lower functioning (BFMF II-V) in the RT group.Conclusion: A community-based upper extremity power-training intervention was feasible and effective at improving power among young people with CP and has the potential to improve pain.

Evaluation of a toolkit for standardizing clinical measures of muscle tone

OBJECTIVE

To evaluate a new portable toolkit for quantifying upper and lower extremity muscle tone in patients with upper motor neuron syndrome (UMNS).

APPROACH

Cross-sectional, multi-site, observational trial to test and validate a new technology.

SETTING

Neurorehabilitation clinics at tertiary care hospitals.

PARTICIPANTS

Four cohorts UMNS patient, >6 mo post acquired brain injury, spinal cord injury, multiple sclerosis and cerebral palsy, and a sample of healthy age-matched adult controls.

MEASURES

Strength: grip, elbow flexor and extensor, and knee extensor; range of motion (ROM): passive ROM (contracture) and passive-active ROM (paresis); objective spasticity: stretch-reflex test for elbow, and pendulum test for knee; subjective spasticity: modified Ashworth scale scores for elbow and knee flexors and extensors.

RESULTS

Measures were acquired for 103 patients from three rehabilitation clinics. Results for patient cohorts were consistent with the literature. Grip strength correlated significantly with elbow muscle strength and all patient populations were significantly weaker in upper- and lower-extremity compared to controls. Strength and paresis were correlated for elbow and knee but neither correlated with contracture. Elbow spasticity correlated with strength and paresis but not contracture. Knee spasticity correlated with strength, and subjective spasticity correlated with contracture.

SIGNIFICANCE

The BioTone^™ toolkit provided comprehensive objective measures for assessing muscle tone in patients with UMNS. The toolkit could be useful for standardizing outcomes measures in clinical trials and for routine practice.

Vertical and Horizontal Jump Capacity in International Cerebral Palsy Football Players

PURPOSE

To evaluate the reliability and validity of vertical and horizontal jump tests in football players with cerebral palsy (FPCP) and to analyze the jump performance differences between current International Federation for Cerebral Palsy Football functional classes (ie, FT5-FT8).

METHODS

A total of 132 international parafootballers (25.8 [6.7] y; 70.0 [9.1] kg; 175.7 [7.3] cm; 22.8 [2.8] kg·m^-2; and 10.7 [7.5] y training experience) participated in the study. The participants were classified according to the International Federation for Cerebral Palsy Football classification rules, and a group of 39 players without cerebral palsy was included in the study as a control group. Football players' vertical and horizontal jump performance was assessed.

RESULTS

All the tests showed good to excellent relative intrasession reliability scores, both in FPCP and in the control group (intraclass correlation = .78-.97, SEM < 10.5%). Significant between-groups differences (P < .001) were obtained in the countermovement jump, standing broad jump, 4 bounds for distance, and triple hop for distance dominant leg and nondominant leg. The control group performed higher/farther jumps with regard to all the FPCP classes, obtaining significant differences and moderate to large effect sizes (ESs) (.85 < ES < 5.54, P < .01). Players in FT8 class (less severe impairments) had significantly higher scores in all the jump tests than players in the lower classes (ES = moderate to large, P < .01).

CONCLUSIONS

The vertical and horizontal jump tests performed in this study could be applied to the classification procedures and protocols for FPCP.

Trunk flexor and extensor muscle performance in chronic stroke patients: a case-control study

BACKGROUND

Although chronic stroke patients commonly show impairment of trunk muscle performance, this disability has only been analyzed in terms of peak torque. Therefore, other measures are needed for a more adequate description.

OBJECTIVE

This study aimed to compare concentric muscle performance of trunk flexor/extensor muscles between chronic stroke patients and matched-healthy subjects.

METHODS

18 chronic stroke patients and 18 healthy subjects were matched according to their age, sex, body mass index and level of physical activity. After familiarization, trunk flexor/extensor concentric muscle strength was measured using an isokinetic dynamometer (Biodex Medical Systems Inc, Shirley, NY, USA) with 3 repetitions at a velocity of 60°/s and 5 repetitions at a velocity of 120°/s. Trunk muscular performance was characterized by peak torque, torque at 90°, total work, and total work normalized by trunk mass. Student's t-test was used for independent samples (α=0.05) for group comparisons.

RESULTS

All trunk muscle performance variables values investigated were significantly lower in chronic stroke patients when compared to matched-healthy subjects (p≤0.001). The obtained ratios of chronic stroke patients scores to that of the matched-healthy subjects at velocities of 60°/s and 120°/s were, respectively: flexor peak torque (60% & 53%)/extensor (54% & 53%); flexor torque at 90° (56.20% & 36.58%)/extensor (57.92% & 30.65%); flexor total muscular work (51.27% & 38.03%)/extensor (47.97% & 39.52%); and flexor total muscular work normalized by trunk mass (55.57% & 40%)/extensor (51.40% & 42%).

CONCLUSIONS

Chronic stroke patients showed decreased trunk muscle performance when compared to matched-healthy subjects in all variables investigated.

Coupling Timing of Interventions With Dose to Optimize Plasticity and Participation in Pediatric Neurologic Populations

PURPOSE

The purpose of this article is to propose that coupling of timing of interventions with dosing of interventions optimizes plasticity and participation in pediatric neurologic conditions, specifically cerebral palsy. Dosing includes frequency, intensity, time per session, and type of intervention. Interventions focus on body structures and function and activity and participation, and both are explored. Known parameters for promoting bone, muscle, and brain plasticity and evidence supporting critical periods of growth during development are reviewed. Although parameters for dosing participation are not yet established, emerging evidence suggests that participation at high intensities has the potential for change. Participation interventions may provide an additional avenue to promote change through the life span. Recommendations for research and clinical practice are presented to stimulate discussions and innovations in research and practice.